Provider Demographics
NPI:1427121607
Name:FITNESS REHAB LLC
Entity type:Organization
Organization Name:FITNESS REHAB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:NACKOS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:801-375-6500
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0307
Mailing Address - Country:US
Mailing Address - Phone:888-700-6907
Mailing Address - Fax:801-294-6917
Practice Address - Street 1:3089 N CANYON RD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3920
Practice Address - Country:US
Practice Address - Phone:801-375-6500
Practice Address - Fax:801-375-6505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5133156-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT51331562400001OtherBLUE CROSS BLUE SHIELD